1. WHO 6 December 2005 Bellagio, Italy Health Systems Development for Equity Ritu Sadana, MSPH, DS Senior Scientist and Policy Analyst Office of the Assistant Director General Evidence and Information for Policy WHO, Geneva

2. WHO 1. 1.Take a systems perspective 2. 2.Context and policies matter 3. 3.Monitor good intentions - for equity

3. WHO What makes up a health system? Social Values Context People's needs Responsibility - accountability Boundaries Goals Functions Inputs

4. WHO SOCIAL GOALS AND SYSTEMS SOCIAL SYSTEMS SOCIAL GOALS EducationHealth Economic PoliticalCulturalOther Education Health Consumption Democratic participation Knowledge Other Responsiveness Fair financing

5. WHO Main Social Goals to Which Health Systems Contribute Health Responsiveness Financial Contribution LEVELDISTRIBUTION QualityEquity x x x x x Efficiency

6. WHO Goals of health systems Improving health status Reducing health inequalities Enhancing responsiveness of systems Protecting people equitably from financial loss associated with ill health

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8. Goals of health systems Improving health status Reducing health inequalities Enhancing responsiveness of systems Protecting people equitably from financial loss associated with ill health

9. WHO Components of Responsiveness Respect for persons –Dignity –Confidentiality –Autonomy –Communication Client Orientation –Prompt attention –Access to social support networks –Quality of basic amenities –Choice of provider

10. WHO Goals of health systems Improving health status Reducing health inequalities Enhancing responsiveness Protecting people equitably from financial loss due to ill health

11. WHO Number of People with Catastrophic Expenditure and Impoverishment Due to Health Spending, Annually

12. WHO Stewardship (oversight) Financing (collecting, pooling and purchasing) FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM Health Fairness in financial contribution Responsiveness Resource development Service delivery (provision) Functions and Goals of Health System INPUTSINPUTS Coverage Efficiency Quality

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14. Distribution of health workers, urban versus rural, Australia Source:Australia's Health Workforce. Productivity Commission Position Paper. Canberra, 2005.

15. WHO % of people not using any service when reporting illness, 13 countries, asset Qs

16. WHO Inequities in access to drugs PoorerRicher Source: Schellenberg et al. THE LANCET Vol 361 February 15, 2003 % children in rural areas with probable pneumonia who received an appropriate antibiotic, 2000 None 0 5 10 15 20 25 30 35 Low2nd3rd4thHighest SES quintiles

17. WHO Effective Coverage Contact Coverage Acceptability Coverage Accessibility Coverage Availability Coverage Tanahashi 1978 Total or Target Population Identification and implementation to "scale up" each type of coverage Universal coverage – effective services to all those in need

18. WHO Inter-country variations in levels of mortality in 67 developing countries explained by indicators of care and context Fuente: World Health Report 2005, pg 83, % of variation explained 0 10 20 60 50 40 30 70 80 90 100 Maternal Mortality Neonatal Mortality Postneonatal Mortality Infant Mortality Unexplained variation Variation explained by financial inputs and responsiveness Variation explained by human resource density Variation explained by interaction between care and context Variation explained by contextual factors

19. WHO } { FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM I N P U T Creatingresources (investment and training) Service delivery (personal and population- based) Stewardship Financing (collecting, pooling and purchasing) Health (level and equity) Responsiveness (to people’s non-medical expectations) Financial protection (and fair distribution of burden of funding) ? Functions and Goals of Health System

20. WHO Stewardship (oversight) Financing (collecting, pooling and purchasing) FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM Health Fairness in financial contribution Responsiveness Resource development Service delivery (provision) Functions and Goals of Health System INPUTSINPUTS Coverage Efficiency Quality How will functions reach objectives? What should be strengthened? How coordinated? How sequenced? How to account for each context? How to align/shape with political agenda? With global influences? With competing priorities? etc.

21. WHO 1. 1.Take a systems perspective 2. 2.Context and policies matter 3. 3.Monitor good intentions - for equity

22. WHO From generic goals to specific objectives: an example Generic goal Improve health status Related national objectives Reduced IMR, MMR Reduced morbidity and mortality related to hypertension Intermediate objectives Increased vaccination coverage Improved quality of antenatal and delivery care Improved access to safe delivery services Improved quality of primary prevention and outpatient management of hypertension Increased patient ability to reduce risk factors Improved maternal and infant nutrition

23. WHO Identify reforms that link to objectives National objective Reduced IMR, MMR Intermediate objectives Financing Function Stewardship Service Delivery Resource Creation Possible reform Monitor compliance with new guidelines Promote production of iron-enriched food Renovate and equip maternity services New GP and family nursing curricula Re-organize PHC Geographic redistribution formula Incentive payments for coverage targets Evidence-based clinical guidelines Increased vaccination coverage Improved quality of antenatal and delivery care Improved access to safe delivery services Improved maternal and infant nutrition

24. WHO TB objectives & system reforms National objective Reduced TB Intermediate objectives Financing Function Stewardship Service Delivery Resource Creation Possible reform Increased vaccination coverage Improved case detection Improved access to quality services Increased cure rates among poor ?

25. WHO "Problem of TB in EURO countries exists principally not because health ministries don’t know about DOTS or that more training is needed – the main obstacles to effective implementation of interventions are systemic and require a coordinated, multi-functional response" Regional Committee Meeting presentation on health systems strengthening, EURO, Sept 05

26. WHO High quality information Components of stewardship, governance, leadership Level autonomy from global processes Beyond health sector Mechanisms exist for Accountability / transparency Social participation and empowerment Exercise……Pre requisites to …… ensuring available intelligence 'tools and rules' coalition building Structure fits strategy Within health sector setting strategic policy direction Right mechanisms to steer the Health System

27. WHO Availability of cause of death data from vital registration systems (192 countries)

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29. Key challenges Level of challengeExamples I. Community and household level Barriers to demand & use of effective interventions (physical, financial, social) II. Health services delivery levelInadequate drugs and medical supplies, mal distributed workers III. Health sector policy and strategic management level Inadequate regulation of pharmaceutical and private sectors and improper industry practices IV. Public policies cutting across sectors Poor availability of communication and transport infrastructure V. Environmental and contextual characteristics Quality of governance

30. WHO Areas for Support & Action – responding to problems and challenges Level of challengeExample areas, questions I. Community and household levelDeveloping comprehensive demand strengthening strategies, informing & meeting expectations of communities II. Health services delivery levelApproaches to support integration of complementary national programs – TB and HIV/AIDS III. Health sector policy and strategic management level Focus on strengthening prerequisites to enable steering role of government Supporting national plans in each key area that address national goals IV. Public policies cutting across sectors Support MoH to better contribute to sector-wide strategies from pro-health and health equity perspective V. Global levelBetter international alignment

31. WHO National level Intermediate level District level Primary Care Services level Community level Nat'l TB P National level Intermediate level District level Nat'l AIDS CP Collaborative Interventions Managerial functions of NTP Planning Resource allocation Logistics Monitoring Supervision Training Service Delivery Functions (NTP) Detecting suspects Diagnosing cases Treating cases Service Delivery Functions (NACP) Counselling & testing Detecting sick people Treating them Promotion & prevention Managerial functions of NACP Planning Resource allocation Logistics Monitoring Supervision Training World Health Organization Example: support to better integrate "vertical" programs

32. WHO 1. 1.Take a systems perspective 2. 2.Context and policies matter 3. 3.Monitor good intentions – for equity

33. WHO Effective Coverage Contact Coverage Acceptability Coverage Accessibility Coverage Availability Coverage Tanahashi 1978 Total or Target Population Identification and implementation to "scale up" each type of coverage Universal coverage – effective services to all those in need

34. WHO Recent studies from child health … Moser et al., BMJ, 2005: examined changes in inequities in 22 countries over 10 year period, using DHS -Mortality highest in poorest vs. least poorest quintile across all countries -4 countries improved average levels, yet 7 countries increase ratio between poorest and least poor

35. WHO Recent studies from child health … Victora et al., Lancet, 2005: examined clustering of preventive interventions in 9 countries, using DHS -Inequities were inversely related to coverage …"raises the possibility that introduction of new technologies might primarily benefit children who are already covered by existing interventions"